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Mental Health For Single Moms
Emergency Shelter AGREEMENT
Note: This form should only be completed by mothers who have been referred and approved by a partner organization.
Indicates required field
Names & Ages of Children
What circumstances have caused you to need emergency shelter?
Shelter From the Rain Emergency Shelter Requirements
I agree that the following are true:
1. I am a single mother/parent and I am not legally married.
2. I am currently homeless and have no other options for shelter.
3. I am pregnant or in custody of at least one of my children.
I agree that I meet all the requirements listed above:
Shelter From the Rain Emergency Shelter Terms & Guidelines
I agree to the following during my stay:
1. I understand that only myself and my children are permitted to stay in the room provided by Shelter From the Rain. If I violate this term, my stay can be terminated immediately.
2. I understand that I am not permitted to charge any other items to the room during my stay.
3. I understand that I am responsible for any damage done to the room during my stay.
4. I understand that I must check out of the hotel on the agreed date set by the hotel.
5. I understand that Shelter From the Rain is not responsible for any items lost, left or stolen during my time at the hotel.
6. I understand that I need to contact Shelter From the Rain at 912-232-5860 if I need to leave the hotel earlier than expected.
7. I understand that this is temporary shelter with a limited number of nights for shelter and I will work on a long-term solution while I am here.
Do you agree to the terms and guidelines of Shelter From the Rain's Emergency Shelter listed above:
Confirmation Check Box - Please Note: If any of the above information is not accurate, emergency shelter can be terminated.
By checking this box, you confirm that the information provided above is accurate.
Shelter From the Rain Inc
Main Diaper Bank: 2203 Abercorn Street, Savannah, GA 31401
Mailing Address: P.O. 24195, Savannah, GA 31405
firstname.lastname@example.org | 912.232.5860
2022-2024 Shelter From the Rain Inc.